Provider Demographics
NPI:1891717120
Name:DODGE, STEVEN CHARLES (BBA;MBA;DC;USN-CDR-R)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:CHARLES
Last Name:DODGE
Suffix:
Gender:M
Credentials:BBA;MBA;DC;USN-CDR-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-4309
Mailing Address - Country:US
Mailing Address - Phone:228-452-0707
Mailing Address - Fax:
Practice Address - Street 1:213 HENDERSON AVE
Practice Address - Street 2:
Practice Address - City:PASS CHRISTIAN
Practice Address - State:MS
Practice Address - Zip Code:39571-4309
Practice Address - Country:US
Practice Address - Phone:228-452-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS925111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS640913280OtherCHIROPRACTOR
MSN/AMedicaid
MSU63008Medicare UPIN
MS640913280OtherCHIROPRACTOR